Burnout and its association with Occupational

Stress among Physicians & Nurse Practitioners

Oluwadamilare.T.Olarinde, Sailaja Nandennagari, Shreya Rekhi & Reshma Annam

Background and Aim​:

To evaluate the relationship between burnout and occupational stress among physicians
and nurse practitioners.
Methods:
Data for this systematic review was based on published peer-reviewed articles that are
publically available. A systematic search was performed in Pubmed. Though the
research was done in 2020, the articles were given a search period range that covered
between 2000 and 2019. The searches identified articles about practicing physicians
and nurses working in civilian settings. Productivity was captured by hours worked,
patients seen, sick leave, leaving the profession, retirement, workload and presenteeism.
Studies also were excluded if: 1) The study did not examine the relationship between
burnout and occupational stress, 2) A validated measure of the burnout was not used, 3)
Articles that primarily looked only at residents or medical students were excluded.
Data Extraction and Synthesis
Burnout in physician articles and study characteristics were extracted independently by
3 investigators. Although meta-analytic pooling was planned, variation in study designs
and burnout ascertainment methods, as well as statistical heterogeneity, made
quantitative pooling inappropriate. Therefore, studies were summarized descriptively
and assessed qualitatively.
Results:
A total of 13 studies from North America met the set inclusion criteria. Cumulatively
examining the results of each study based on the Maslach Burnout Inventory (MBI)
evidently displayed a correlation between burnout and occupational stress among
physicians and nurse practitioners. The respective articles used in this review allowed
for inclusion and exclusion criteria to impose a limitation on biases. A posted
comparison of each peer-reviewed article can be seen in Table 3.
Conclusion:
Overall the studies examined in our paper display a high correlation between burnout
and occupational stress among physicians and nurse practitioners. It is evident that a
correlation is present. However taking into consideration various factors such as
occupation specialities and personal life problems can be something further examined
to eliminate any biases and outliers. Further interventions trying to reduce burnout and
increase the satisfaction experienced by physicians can be a target .
Introduction
Burnout was a term first defined by Herbert Freudenberger as “​exhaustion resulting from
excessive demands on energy, strength, or resources in the workplace, characterizing it by a set
of symptoms including malaise, fatigue, frustration, cynicism, and inefficacy” (Reith.T, 2018).
Later, Christina Maslach added to his understanding and created a model of burnout which
consisted of three dimensions: emotional exhaustion, depersonalization and a diminished sense
of personal accomplishment(​Maslach et al 1997)​.
In emotional exhaustion, we see an overwhelming work demand that depletes the
individual’s energy; depersonalization and cynicism, in which the individual detaches from the
job and feelings of inefficacy, in which the individual perceives a lack of personal
accomplishment. In 1981, the Maslach Burnout Inventory (MBI) was invented to measure an
individual's symptoms within each of the three subscales present. The MBI is the most used
instrument in measuring and assessing the burnout of an individual even today (Reith. T, 2018).
Burnout with its long term effects is known to put physicians at risk for poor mental health,
decreased productivity, and abandonment of career medicine, it is therefore understood that
burnout is a detrimental component of patient care (Reith.T, 2018).
Health care professionals: physicians and nurses are known to be people who are highly
susceptible to experience burnout given their long education period, high stress environment and
grueling working environment. Studies have shown that physician burnout affects both patients
and physicians, and due to this, burnout within the medical community is of grave concern.
Recent studies estimated that more than half of all physicians in the United States currently
are experiencing burnout after controlling for hours worked, age, sex, and other factors and
comparing to other professionals. Data collected from the 2013 Medscape Lifestyle Report
displayed a 25% increase in reported cases of burnout from 40% to 51% within a four year
period (Reith.T, 2018). Therefore, the objective of this review was to ​evaluate the relationship
between burnout and occupational stress among physicians and nurse practitioners.

Methods
The MEDLINE and PubMed databases were searched for peer-reviewed primary data studies of
burnout among physicians and nurses published in the English language and used a
well-described method to assess burnout. The search was conducted using combinations of the
following Medical Subject Heading terms: ​burnout, physicians, nurses​; ​occupation stress​; or
emotional exhaustion​; and ​residen​t. The search was limited to articles published between 2000
and January 2020.
This search yielded a total of 345 articles. Abstracts from this list were reviewed by the author
and references were selected for retrieval if they are the reports of primary data collection that
specifically focused on burnout or the dimensions of burnout among residents. As some known
references were missing from this database search, reference lists of these articles were then
examined for other relevant studies. A total of 10 articles on resident burnout were thus
identified.
 Three authors independently identified cross-sectional studies published before January 2020
which includes articles related to burnout among practicing physicians as well as nurse
practitioners (ie, excluding medical students and resident physicians) through systematic
searching of MEDLINE/PubMed. For the database searches, terms related to physicians and
occupation stress were combined with those related to burnout without language restriction.
Studies that reported data on burnout in practicing physicians, those published in peer-reviewed
journals and those used a well-described method for assessment of burnout were included.

Flow Chart Synthesis :

Figure:1, ​Flow chart synthesis:
Search through the database yielded
345 records and 8 additional were
found out through hand searching.
After excluding 302 articles based on
the title, 51 citations were retrieved
followed by exclusion of 26 articles
based on abstract and remained with
25 articles. When these 25 articles
were screened, 4 articles were
excluded after evaluation of full text, 3
were excluded due to non-availability
of full text and 3 more articles were
excluded as they are not original.
Remaining 15 articles are screened
for eligibility criteria and from those
4 are excluded depending on inclusion
and exclusion criteria. 11 articles are
retrieved based on inclusion criteria
Along with two articles retrieved from
search of references, totaling 13
articles included in this review.​]

Screening Process
Relevant articles were identified using a multi-phase screening process. To identify relevant
articles, search results were screened first by title, then by abstract and in the final screening
process, by full-text review. Articles for which the title and abstract did not provide sufficient
information to determine relevance were considered in the full-text review. Inclusion criteria
were: Burnout was measured using the Maslach Burnout Inventory (MBI), Professional Quality
of Life (ProQOL), Abendroth Demographic Questionnaire, Mini Z burnout survey and
Parameters similar to the ones used in MBI.
 Quality Assessment
13 studies were assessed. Most of the studies had a silent comparison Some articles reported on
confounding factors such as age, years of experience,
1. Study well described (age, location of the study, physician specialty, practice location)
2. Data collection methods are described
3. Burnout assessed using a validated measure, MBI

Table 1: Studies included in the systematic review of the relationship between burnout and
occupational stress among Physicians and Nurse practitioners

​ he characteristics of the participants, the sample size, period of study, country of study, study design and
[T
diagnostic criteria for burnout and the covariates examined in each study are described in Table 1. The
studies that met our inclusion criteria comprised a total of # individuals (add up the total sample size). All
studies were conducted in the United States of America.]
*MBI: MASLACH BURNOUT INVENTORY
*ProQOL: PROFESSIONAL QUALITY OF LIFE
Table 2: Details of listed studies such as comparison and methods of adjusting confounding
illustrated as below

[Table 2 presents the methodological quality of the included studies. Of the 11 studies, # had no
comparison groups, # had comparison groups, and in # the comparison groups were not clear.
In all 7 trials investigators were aware of the treatment allocation.]

Results
Based on our research the collected data displays a direct correlation between burnout and
occupational stress among physicians and nurse practitioners. All thirteen articles used in this
study were cross-sectional studies. Physicians within the studies were from various streams of
specialities within the United States of America from 2003-2017 (Table 1). The number of
participants within each study ranged from 146-7228 people.
Most studies used a version of the Maslach Burnout Inventory (MBI) scale to assess the
burnout experienced by physicians and nurses, some however also used ProQOL, Abendroth
Demographic Questionnaire and Mini Z burnout survey (Table 1).
Both MBI versions ask survey takers to rate how often they experience specific feelings of
burnout at work on a 7-point Likert scale, with 0 representing “never” and 6 “every day” (Lisa et
al, 2018). Furthermore, a close comparison within each study displayed that ​regardless of the
version of MBI used, higher scores on the emotional exhaustion and depersonalization subscales
and lower scores on the personal accomplishment subscale correspond to higher levels of
burnout (Lisa et al, 2018).

Table 3: Effect of Occupational Stress on Physician’s Burnout symptoms, 2000—2019

Abbreviations: DP: Depersonalization, EE: Emotional Exhaustion, MBI: Maslach Burnout

Inventory, NR: Not Reported, STS: Secondary Traumatic Stress, B: Burnout, CS: Compassion
Satisfaction.
Discussion
The majority of the studies used an inventory based on the MBI, which considers burnout
consisting of 3 domains: Emotional exhaustion, depersonalization and low personal
accomplishment.
This review identified a lack of consensus on how the burnout construct is used to measure
physician’s exposure and response to occupational stress. Although a prevalence of 50% for
physician burnout has been cited in the popular press and academic literature, the heterogeneity
between the assessed studies calls into question whether any prevalence estimate cited for
burnout can be meaningfully interpreted.
Research on burnout among physicians has increased awareness of physician mental health
and well-being as an important issue, and US national organizations have recently called for all
health care systems to assess their physicians on the measures of well-being, often with a focus
on burnout. This review indicates that a more consistent definition of burnout and improved
assessment tools may be necessary if these policy measures are to successfully improve the
physician work environment.

Strengths:
● Very systematically synthesized and organised with adequate transparency
● Synthesis of articles increased the scope of the article
● Article provides overall idea about the relationship between and occupational stress
among physicians and nurses
● Information seeking skills from various related articles through the process of scanning
databases with the help of strings can be effectively learnt

Limitations:
● Limitation of creativity
● Relies on database that support keyword search only
● Related secondary data is not available
● The search strings must be identifiable

Conclusion
Our findings from the papers examined identify that there is a heavy percentage of positive
correlation between burnout and occupational stress among physicians as well as nurse
practitioners. Further examination of the study can be done to eliminate bias resulting from
various specialities, personal issues.
Research can be broadened out to identify the burnout due to personal issues alone including
financial stress, family matters, work environment, relationship with colleagues etc. And also
other health care professionals such as paramedics also can be involved in the study.
Further interventions can be carried out to reduce the curve of burnout among healthcare
professionals which results in quality healthcare delivery leading to a healthy community, a basic
necessity of the society.
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